Medicare plans

A special tax credit meant to reduce the cost of health insurance premiums for low and moderate-income people. Eligibility is based on income and family size. In order to receive the tax credit you need to complete your health insurance application through the online Health Insurance Marketplace in your state.
Premium Tax Credit

The Affordable Care Act was passed by Congress and then signed into law by President Obama on March 23, 2010. The law is meant to make health insurance accessible to more Americans. It also provides certain consumer protections, such as eliminating pre-existing conditions, and requiring insurers to cover preventive services – such as annual check-ups and immunizations -- without any out-of-pocket expenses to the consumer.
Affordable Care Act (ACA)

A written request from the enrolled member or the enrolled member's authorized representative to reconsider an initial adverse determination to deny coverage of service or payment of a claim, including delay in providing, arranging for, or approving the healthcare service.
Appeal

The beneficiary is enrolled in a health insurance plan and receives benefits through those policies.
Beneficiary

The medical care for you and your dependents that is covered by your insurance either directly or through reimbursement. Also includes dental care and prescription medications.
Benefits

CMS is the federal agency which administers Medicare, Medicaid, and the Children's Health Insurance Program. It is the primary governing entity for the Medicare Advantage Program.
Centers for Medicare & Medicaid Services (CMS)

A request by an individual (or his or her provider) to an individual’s insurance company for the insurance company to pay for services obtained from a health care professional.
Claim

The refusal of an insurance company or carrier to honor a request by an individual (or his or her provider) to pay for health care services obtained from a health care professional.
Claim denial

COBRA stands for the Consolidated Omnibus Budget Reconciliation Act of 1985, federal legislation that allows you – if you work for an insured employer group of 20 or more employees – to continue to purchase health insurance for up to 18 months if you lose your job, or if your employer-sponsored coverage is otherwise terminated.
COBRA

The percentage of the total cost of covered services you must pay after you meet the deductible. Your plan pays the higher percentage (e.g. 80%) and you pay the lower percentage (e.g. 20%)
Coinsurance

A copayment is a predetermined (flat) fee that you, as a member of the insurance plan, pay out-of-pocket for certain services – such as a doctor's visit – at the time services are received. Copayments are not usually specified by percentages.
Copayment

Refers to medical expenses that are shared by you and your insurer. Co-insurance, doctor visit copayments and deductibles are all forms of cost sharing. Premiums, payments for uncovered health care services or fees paid to out-of-network providers are not shared costs.
Cost-sharing

The amount that you – either by yourself or in combination with other covered family members – pay for covered in-network services each year before the plan covers the costs. There's also a separate out-of-network deductible.
Deductible

Insurance coverage that extends to the insured's dependents, including spouse and dependent children.
Dependent Coverage

Most plans with Medicare drug coverage (Part D) reach a coverage gap called a “donut hole.” After you and the drug plan have spent a certain amount on medications each year, the drugs are no longer reimbursed and you pay 100% of the cost. Under the Affordable Care Act, those who reach the gap now receive a 50% discount on brand-name prescriptions. Those taking generic drugs receive a 14% discount. The coverage gap will continue to shrink until it’s eliminated completely in 2020.
Donut Hole

Every insurance plan must include a core package of what’s called Essential Benefits in 10 categories. These benefits include coverage for a hospital stay, preventive and wellness doctor’s visits, mental health treatment, lab services (for example, blood tests), prescription drugs, and maternity and newborn care, among others.
Essential Health Benefits

See Health Insurance Marketplace
Exchanges

An exclusion is a provision within a health insurance policy that eliminates coverage for certain acts, property, types of damage or locations.
Exclusion

Insurance provided to a select group of people – for example, an employer that offers health insurance to its employees. Group plans are generally uniform in nature, offering the same benefits to all of its members.
Group health insurance

Called the “Guaranteed Availability of Insurance,” this rule requires health insurers to accept every eligible individual who applies for coverage, including those with an existing health condition or a history of health problems.
Guaranteed Coverage

Healthcare Reform refers to the Affordable Care Act, which was signed into law on March 23, 2010. See also Affordable Care Act.
Healthcare Reform

Think of The Health Insurance Marketplace (also known as an "Exchange") as a virtual online "mall" where you can shop for health insurance. These Marketplaces allow individuals and small businesses to compare health plans -- such as those offered by Humana -- side-by-side, get answers to questions, find out if they are eligible for subsidies to help pay for their insurance and enroll in a health plan. Each state utilizes either the Federal Marketplace, or a state-based Marketplace.
Health Insurance Marketplace

A plan that features higher deductibles than traditional insurance plans. HDHPs can be combined with a health savings account to allow you to pay for qualified out-of-pocket medical expenses on a pre-tax basis. An HDHP is usually a Preferred Provider Organization (PPO) plan, but it also could be an HMO or Point of Service plan.
High-Deductible Health Plan (HDHP)

With an HMO, you select a primary care physician (PCP) who is in the plan's network. Your personal doctor tends to most of your health needs and refers you to a specialist in the network when necessary.
HMO (Health Maintenance Organization)

Policies for people who don’t get their insurance through an employer-based group plan.
Individual health insurance

The Individual Mandate is the requirement under the Affordable Care Act that most U.S. citizens have health insurance. Exceptions to the rule include those whose religious beliefs bar them from using health insurance benefits, those with a family income so low that they aren’t required to file a tax return, those who would have to pay more than 8% of their income on insurance (after factoring in any tax credits and employer contributions) and undocumented immigrants.
Individual Mandate

Insurers such as Humana negotiate lower rates from specific doctors, hospitals, and other providers, so these providers are part of the insurer’s network and are referred to as "in-network" providers. Also called "participating providers."
In-Network

The maximum amount your plan will pay toward eligible expenses while you're covered under the plan. As a result of the Affordable Care Act, insurers may no longer impose lifetime limits on key benefits, such as hospitalization.
Lifetime limits

Each state operates a Medicaid program that provides health coverage for lower-income people, families and children, the elderly, and people with disabilities. The eligibility rules for Medicaid are different for each state, but most states offer coverage for adults with children at some income level. To learn more about your state’s program visit Medicaid.gov.
Medicaid

A rule called the Medical Loss Ratio requires your insurer to put at least 80% (85% for large groups) of premium dollars collected towards covering medical costs or improving quality of care. Administrative and other costs are limited to 20%.
Medical Loss Ratio

Medicare is the federal health insurance program available to people 65 years of age or older. Medicare is also available to younger people with certain disabilities and people with end-stage renal disease.
Medicare

A Medicare plan offered by a private insurer, such as Humana, which includes all of the benefits of Original Medicare and may also include Medicare Part D prescription drug coverage, as well as extra benefits. When you have a Medicare Advantage plan, you still have Medicare and must continue paying Medicare premiums.
Medicare Advantage Plan

Mental health care includes services and programs to help diagnose and treat mental and behavioral conditions.
Mental health services

A group of doctors, hospitals and other healthcare providers contracted to provide services to insurance companies’ customers for less than their usual fees. Provider networks can cover a large geographic market or a wide range of health care services. Insured individuals typically pay less for using a network provider. Also called “participating providers” and “in-network providers.”
Network

Also called "non-participating provider," this term refers to providers who are not part of an insurance company’s network and, therefore, will cost you more.
Out-of-network

The predetermined annual limit on the amount you must pay for medical expenses. After you meet the maximum out-of-pocket amount, your plan pays 100 percent for covered services. You may still pay copayments.
Out-of-pocket maximum

Under the Affordable Care Act, the Patient's Bill of Rights provides certain consumer protections regarding health insurance coverage. Examples include giving parents the option to keep their adult children on their health insurance plan until age 26, eliminating pre-existing condition exclusions, and ending annual and lifetime limits on the amount of qualified medical expenses your insurer will cover.
Patient’s Bill of Rights

PCP is short for Primary Care Physician – a doctor who is chosen by enrolled members of HMO plans to coordinate and manage all of their healthcare.
PCP

A Private-Fee-for-Service (PFFS) plan is a Medicare Advantage plan that allows its members to use any doctor, specialist, or hospital that participates with Medicare, accepts Medicare payment, and accepts the terms, conditions, and payment rate of its insurance company, which is based upon Original Medicare payment calculations.
PFFS

A type of plan in which you pay less if you use doctors, hospitals, and other health care providers that belong to the plan’s network. POS plans may require you to get a referral from your primary care doctor in order to see a specialist.
POS (Point-of-Service)

PPO is short for a Preferred Provider Organization, a type of health plan that gives you the freedom to choose your own doctors and hospitals. Your out-of-pocket costs are usually lower if you choose healthcare providers who participate in the plan's network.
PPO

A pre-existing condition is a medical condition that is excluded from coverage by an insurance company because the condition was believed to exist prior to the individual obtaining a policy from the particular insurance company. Starting in 2010 with the passage of the Affordable Care Act medical plans, except non-grandfathered individual plans, could not impose a pre-existing condition limitation or exclusion on children under 19 years of age. As of 2014, adults have this same protection.
Pre-existing condition

Services that prevent illness or detect illness at an early stage, such as flu shots and screening mammograms. Under the Affordable Care Act, insurers are required to provide no-cost annual check-ups, health screenings, and immunizations to kids and adults alike.
Preventive care

Provider is a term used for health professionals who provide health care services. Sometimes the term refers only to physicians. Often, however, the term also refers to other health care professionals such as hospitals, nurse practitioners, chiropractors, physical therapists, and others offering specialized health care services.
Provider

Some conditions require the care of a doctor with narrower but deeper skills than a primary care physician can offer. A cardiologist, for example, knows more about the heart; a dermatologist knows more about diseases of the skin.
Specialist visits

Individual subsidies – part of the Affordable Care Act -- help low to moderate-income people afford health insurance. One form of subsidy is a monthly tax credit to put toward the cost of premiums. Another is a reduction of some out-of-pocket medical expenses, such as the deductible and co-pays for doctor’s visits. Financial assistance is based on family size and income and is only available if you buy your insurance on one of the Health Insurance Marketplaces. The Marketplaces offer plans from a wide range of insurers, including Humana.
Subsidy

Under the Affordable Care Act, insurance companies are required to provide consumers with a clear, concise summary of their plan benefits, allowing them to easily compare plans and/or insurers. The law calls it Summary of Benefits and Coverage (SBC). Standardized language is used across all insurance carriers, making it easy to compare apples to apples when evaluating plans.
Summary of Benefits and Coverage (SBC)

Urgent care centers – also called walk-in clinics -- provide a good medical and financial alternative when you can't see your regular doctor, and your illness or injury is relatively minor. Urgent care centers have shorter wait times, don't require an appointment, are open evenings and weekends, and cost less than an emergency room.
Urgent Care Center

A program intended to improve and promote health and fitness. While sometimes offered through work, insurance plans such as Humana may also offer them directly to their members. Some examples of wellness programs include programs to help you stop smoking, manage diabetes or lose weight. Under the Humana Vitality Program, members earn points when they make healthy living choices such as eating nutritious foods and working out. Their points can be cashed in for things like movie tickets, iPods and exercise equipment such as bikes.
Wellness Program

This information is only a high-level summary of certain provisions of the health care law. This information does NOT attempt to summarize all provisions of the health care reform law. This information is not and should NOT be used as legal or tax advice; it should not be used as a basis for decisions regarding how the health care reform law will affect you and/or your business. Should you have any questions on how the health care reform law (including the high level summary of certain provisions of health care reform) will affect you and/or your business, you should seek professional advice from attorneys or other advisors.

For Arizona residents: Insured by Humana Insurance Company. For Texas residents: Insured by Humana Insurance Company or offered by Humana Health Plan of Texas, Inc.

Our health benefit plans have exclusions and limitations and terms under which the coverage may be continued in force or discontinued. For costs and complete details of the coverage, call or write your Humana insurance agent or broker.